Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer two prescribed medications, cholecalciferol and Miralax, to a resident as ordered by the physician. The resident, who had a history of gastrostomy, respiratory failure, and peritoneal abscess, was dependent on staff for all activities of daily living and had moderately impaired cognitive skills. The resident's medication administration record indicated that both cholecalciferol and Miralax were scheduled to be given via G-tube at 9 AM, along with other medications. During a medication pass observation, the LVN administered all other scheduled medications but omitted cholecalciferol and Miralax without realizing the error at the time. Upon review and interview, the LVN acknowledged the omission and stated that medications could be given within a one-hour window before or after the scheduled time, but did not administer the missed medications during the observed period. The Director of Nursing confirmed that the LVN should have followed the physician's orders and administered all scheduled medications as prescribed. Facility policy required medications to be administered safely, timely, and in accordance with prescriber orders, which was not followed in this instance.